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The current health care model for trans * people many times is defended as protecting the patient. Protecting them against regrets. A physician wants to be sure the patient they see, is serious, is not acting on impulse. This worry we can understand, the solution however is wrong.

A large part of the worries that physicians have regarding autonomous trans people comes from fear and ignorance. Fear of loss of work and also loss of authority.

Fear of people taking decisions they will later regret and will hold the doctor responsible for. Only to bring them before the disciplinary board. That is traumatic for the physician, when they have done their best to deliver a good job on explicit request. Incomprehension because they do not understand trans* people. They haven’t learnt a thing about them during their studies of psychology, psychiatry or medicine. And if something is taught, that is mostly rather out of date. Only this year thinking progressed slightly with the introduction of the new DSM and a new nomenclature for trans* issues.

A trans* patient does not need more or different protection than a non-trans* patient. Just as a Swedish patient needs no more or better protection than a French one. Where a doctor cares for the mental health of a patient because they do not appear to be stable, this mental stability is the problem. Not the being trans* of the person. The question should be: If I would have a patient with an appendicitis, or for cancer surgery, would I also require a psychologist’s certificate about their well-being? The fact that something is culturally loaded, is not enough reason to as for extra intervention/extra control.

Also everyone has a right to regret. However cynical that may sound. It is very well possible a trans* person who comes out is not sure of themselves. Identity develops. The same with gay and lesbian and bisexual people. Many times they are not coming out because they feel so great with the idea. Often they only do so when a lover is in sight, although they feel their being different for a much longer time already. They don’t need to see a psychologist, they have no longer a disorder (since 1991). Not coming out, living a non-authentic life, is something you can regret also. Like you can regret marrying, or not marrying. Or having children, or deciding not to have them. No one can tell if things will work out the way it was intended. So I would almost state: also trans people have the right not to be happy with their life and their choices. It is anyway not up to the state or the medical profession to always try to prevent us from failing, from regretting. Or should we also send prospective parents first to a psychologist or sexologist? Prospective spouses to a marriage counselor to have their love tested on stability, on longevity?

That fear we would decide for ourselves, for prosecution because they helped the ‘wrong’ trans person also stems from fear and ignorance. First of all, informed consent should be a requirement. With or without a psychologist, if the patient doesn’t understand what is involved, at is where it ends. Secondly, it won’t be the first time a medical psychologist would be involved when a patient has to undergo invasive treatment. But not all patients that undergo say oncological treatment will have to see a psychologist.

When society stops freaking out about trans* people, the suffering will decline enormously. After all, it is the outside world that gives us a lot of our trouble. And we as a part of that world got the message that it is not good to behave as we do, to feel like we do. So, stop freaking out and join the revolution. We are nothing more than a threat to your mental status quo. So what.

The press release of the Amsterdam gender team they sent out on Wednesday December 18, stating they cannot treat all the people who applied in recent times constitutes a brilliant opportunity to stop diagnosing trans people with gender dysphoria and start an informed consent based treatment process.

The day after the glorious victory of the passing of a strongly improved gender recognition law in the Netherlands, the Amsterdam Gender team that treats 85% of Dutch trans people who need a bodily and/or legal gender change, published a press realease saying they may stop accepting new patients within half a year. Where there is an increase of 500% of applications in recent times, they do not get enough extra money to help them.

Of course this a bad development. When health care cannot be delivered people lose their right to health on certain points. On the other hand, with the attention because of the adoption of the new law, this is a form of blackmail. A way to hopefully get government and insurance companies around the table. Completely legitimate.

But as usual there is a back story to this. Dutch government designated the VUmc team as the Expert Centre on transgender Health in the Netherlands. And persistent rumours have it they use this position to create an oligopoly, having only the UMCG in Groningen that caters for the northern provinces, as their collegial competition. A small department at LUMC in Leyden treats trans* children.VUmc actively discourages surgeons or endocrinologists working elsewhere to treat trans* people. When psychologists elsewhere want to diagnose trans* people so they can have their bodily and legal changes, these are also discouraged.

I do no tell this to badmouth the work they do. This means to explain part of the origin of the problem. And probably from their point of view it is completely legitimate. So they need a good solution. Well, that is easy. Tell the psychologists to stop diagnosing their “patients”. That will save millions of euros.

Alternatively a better way of spending the money they got and the money they still need, lies in helping trans* people cope with the transphobia they experience. And with their internalised transphobia they develop from all the bad reactions. Psychologists are good at helping people get rid of many complaints and otherwise learn them cope with other issues. Transphobia (society’s reaction to people who do not fall within the accepted limits of male/female) causes depression and anxiety and more. Suicidal tendencies. That needs to be helped. But diagnosing trans people with gender dysphoria (DSM-5) or gender identity disorder (ICD-10) or gender incongruence (ICD-11, proposal) does not work. I imagine these psychologists would be far more proud of their work also, would feel more qualified ease these complaints than diagnose people with a non existing disorder. Additionally it will still be cheaper since not everybody needs this help.

From midnight tonight six trans* activists In Andalusia, Spain will start a permanent hunger strike until either the bill for better trans legislation that is stuck, will be really introduced in Parliament or until they die.Continue reading

October 19, 2013 is the international day on the depathologisation, declaring not a disorder but a positive diversity, of trans people. And because of high level developments in the World Health Organisation, that is responsible for revising the International Classification of Diseases, that is used for understanding what is a sickness, a disease, a disorder – be somatic or psychological. This is a global Classification – unlike the DSM that is still mostly US based but having a wider use. Here in NL psychologists use it, health insurers use it. For adolescents and adults there is a positive change going on, although the battle is not yet won. Because of this last issue, introducing a diagnosis for children, and 2014 being a decisive year for the new ICD, the pathologisation of trans children has been chosen as the theme for this year.

The suggestion for a theme usually comes from Spain where the campaign started in 2009. It was the time that the process to change the DSM started and they started to create global awareness for the changes. After all: the DSM still declares trans* people having a mental health problem. And when the process to change the ICD got under way, this had been taken into the campaign. Nowadays a strong focus of advocacy for trans health lies in getting a good description in the ICD-11. Since that will be decisive for how many people in the medical and political world will see us. If trans people are not (mentally) ill, but instead suffer from society, we will be taken more seriously. So that is why today and why the theme.

What is today about?

I will first define the situation: gender kids are not welcome as who they are, most learn to hide very early in life. I have recent data from the UK on that. Next I will give an overview of several developments in the social and the medical world. I will focus on how the big international classifications that are in use. By that I mean the infamous Diagnostic Statistical Manual of menatl disorders (DSM, version 5) of the American Psychiatric Association (APA) and the global, more responsible International Classiication of Diseases (ICD, version 10) of the World Health Organisation (WHO). Developments there are going in the wrong direction. And that has pretty much to do with it being children and with queerphobia.

Also I will give an update on developments in the Netherlands; what support is there, how are parents reacting? What does the clinic do? What would be good ways to advance our case for gender freedom?

Trans*

To start with trans*: this is not just transgender in the transitioning variant. It can surely mean transgressing gender norms, being and behaving gender non conforming. Because trans* is who trans* does. In a way many of you are also trans*: you do trans*, you transgress gender norms. Don’t come to me “Hey, but I’m fine with my body”. That is just one version of gender diversity, of trans*. Being trans* does not require gender dysphoria or gender incongruence or however you call it. And trans* is not just identity, it is also expression. Since so much what we all gay or lesbian or bi, is more gender expression than sexual orientation or gender identity.

So trans* can be anything non gender conforming. And acceptance for that already is quite low for kids. While the Netherlands may be relatively tolerant of it, and many young parents seem to be, recent UK data show that also the seemingly more accepted tomboy behaviour of girls and non apparent trans boys is not really accepted. Non-apparent then stands for people who later in life tell to be trans already from early on but didn’t tell anybody back then.

Kids

And by kids I mean children before puberty hits them, which roughly mean between 10 and 12 years old. Usually one says: puberty starts with Tanner stage 2. Then physical changes start appearing. In the Netherlands that gets ever earlier, and in several other countries also.

Although it is a generally accepted idea that children change, that change and development are the core phenomena of a child’s life, many implicit norms govern this period. A good example is that there is an Amsterdam kindergarten where children of many gay and lesbian parents spend their day. The personnel are very happy with the lesbian and even more with the gay parents. However all the kids are neatly divided in boys and girls and treated differently. I think this has much to do with idea that being gay and lesbian is seen as only a relationship thing, a sexuality thing, something private. Gays can be great parents also! But this goes completely beyond the point that so much is gendered behaviour, based on gender identity and/or expression.

Sterlisation is for cats, not for me

ICD

It is clear that the Committee that manages the chapters relevant to trans people is convinced gender identity issues must be relabeled en get a different position. The name is in the process of being changed from “Gender Identity Disorder” to “Gender Incongruence”. A mismatch between body and felt identity. That is better already, better also than Gender Dysphoria. But:

Why must there be such a diagnosis? The gender identity is not wrong, just different.

Being non trans*, the default situation of being cisgendered, still is the definition of Normal

A new diagnosis is being introduced that concerns trans* children. So a child living differently is still bad, wrong

It is the WHO that decides through scientific research what is to be considered a sickness, illness or disorder. Everything health related is in their remit. For the description of diseases etc. there is the International Classification of Diseases, ICD for its abbreviation. It is going to version 11 now, after the longest time between versions. ICD-10 is from 1990 and got in to function in 1994. Since 20 years is a long long time, the changes will be drastic, and many things will change: biomedical sciences have advanced enormously and everything may be streamlined more than before. So it will also be in things transgender related.

But the WHO is not only purely scientific and apolitically health care related. LGBTI issues face enormous contention from the usual suspects of human rights refusers for LGBTI people: the Vatican, the African group Russia and some consorts, several countries united in the Organisation for Islamic Cooperation. Recently there was to be a discussion about discussing LGBTI health issues and the issue got removed form the agenda thanks to pressure from these countries. For now the tendency within WHO is to declare it a technical issue and remove it from the agenda because of too fierce resistance.

Trans identity issues are now going from the horrible: Gender Identity Disorder” to most probably “Gender Incongruence”. The DSM 5, that American horrible psychiatric classification uses gender dysphoria. Incongruence is the least harmful term of the three, but still does not take its departure in gender diversity with all gender identities equally valid. So tis still not good. Gender dysphoria means one has lots of stress, anxiety, depression because of ones trans identity. Which is another case of wrong angle: it is not the identity in itself that causes so much trouble, it is how the world reacts and how one learns to look at it. And you know already quite young if it is OK to live like you feel. Which is why many trans people only come out later in life. Lucky the people who have enough to support to come out young. And can more or less freely develop their identities.

Gender Incongruence only means that your body and your identity do not match, are not congruent. But that still is not good enough of course. It is doable and better than dysphoria, but still.

The bad new thing for this Classification is that suddenly trans kids*, those who are not adolescents, the K-12 kids, need a separate, autonomous diagnosis of their Gender Incongruence. It will then be called, gender incongruence in children. But there are a couple of strange or incorrect things with this.

An important detail to add is that the proposal is to have the diagnosis onl apply to those children with severe complaints. Not every kid with a non traditional gender expression would fall under it. Only those whith “severe incongruence” as I imagine the wording might be. The fear for gendernon conforming behaviour seems to lessen in these circles. because they aslo say this with adults adn adolerscents, lready in the DSM-5.

First and foremost: they are sort of de-pyscho-pathologising adults. Because adults will be in a separate chapter for gender identity stuff, or in a chapter on sexual health. Not any more in the current chapter (F.64) of mental and behavioural disorders. But since children below puberty cannot get puberty blockers, there is nothing medical with them, so diagnosing them is diagnosing their – changing and developing – identity, means putting them with mental health issues.

When there is nothing medical, there is no need for diagnosing. So it is irrelevant. Surely since psychosocial support can be arranged through already existing constructions. This way a new class of experts and of treatment will be created. And once created, a specialism doesn’t want to close down.

Situation of trans kids according to research

Since this is all about trans* kids, it would be good to know a bit more about how they live, what their problems are. The problem is: there is only very little research in this. And most comes form the medical/psychiatric division of society. Not only that, it comes from researchers with a strong agenda for normalization. A name to remember in this is Kenneth Zucker from Toronto. In Berlin, Germany there is professor Klaus Beyer working with trans* kids who also has clearly non respecting ideas. Don’t get your kids to the Charité hospital in Berlin if they are queer.

The problem with Zucker and his pal Richard Green is their disrespect for the autonomy of trans people. Green is the author of “The sissy-boy syndrome”. He is Zucker’s predecessor and together they try to make a strong case for reparative therapy. This means: attempt to -de-transgender the kids, to un-gay them. Because gay and trans is Wrong. And trans is worse than gay (that is at lest within the gender binary). In the Netherlands people like these do not work at the gender clinics, but they might run loose as independent psychiatrists. Which might be even more dangerous: if the parents don’t know about the gender clinic’s youth program or better about Transvisie Zorg, the child might suffer much.

Natacha Kennedy

From recent UK research by Natacha Kennedy we know that of the respondents to an online survey most were ‘non apparent” trans kids. That is: they felt different already early in life but came out far later because they knew it was not considered a good thing to be trans. Already at age 8 the social radar of all children is god enough to realize this. There is no majority of one type of trans* in this research: the respondents have come out as cross dressers, transgender, genderqueer, mixed gender. The consequence of this feeling already quite young to be apart, different form the others leads to the feeling of not being able to live as one wants, to invest a lot in a gender identity that is not one’s own.

That does not have to contradict our cherished idea that gender is doing. It appears many people who live one thing, slurp, suck in what they are actually more interested in. To quote Butler in this: “Femininity is thus not the product of a choice, but the forcible citation of a norm, one whose complex historicity is indissociable from relations of discipline, regulation, punishment.” (Bodies that matter). Anyone wonder about the appearance of “gender dysphoria” then?

This nonrecognition of gender diversity is something seemingly universal. Surely here in the Netherlands the idea of gender expression is not very developed in general discourse.

Support

So what is there in support? As it is said the Netherlands is doing very well in medical support for adolescents, the question of course is: what is there for the young one? Well, there is support from Transvisie Zorg that have a social worker and a sexologist who see the parents, visit schools, talk to schools, see the kids if they want. Most of their work is with the adolescents, but a growing number of parents call for support. Their list of visited schools grows at 40 schools per annum!

The most common phenomenon roughly from 10 on, is bullying. More girlish boys than boyish girls get bullied. However every school got protocols against bullying. When talking with schools Transvisie points at bullying and the need prevent this, but it is mostly up to the kid and their parents to go to school and tell the staff they get bullied.

And then there is the gender clinic that gives “temporary” diagnoses. Precisely in the idea the ICD want s to have that diagnosis: to make it easier to enroll in the adolescent program. How good the support is, depends very much on the quality and opinions of the psychologist.

The last word on this may not yet be said, but the people shouting victory over what for The American Psychiatric Association is a big step but just a very tiny one for humankind, means some clear language is needed to provide an exit out of this quagmire of pathologisation, half depathologisation and repathologisation.

Once upon a time, some twelve years ago the latest edition of the DSM saw the light: DSM-IV-TR. A text revision of the DSM IV that is even older (1994). There transgender was classified under 302.x “Gender Identity DIsorder” Jawohl, a full fledged mental disorder. Before it was transsexuality. Also something not be happy with. You had to suffer quite a lot, and conform to the descriptions in bible of transsexuality, Harry Benjamin’s Transsexual Phenomenon, absolutely feel The Other Gender, from the moment you had any self perception. You wanted to be a woman (mostly, sometimes a man). You may live in a homosexual relationship but was because you actually were a woman, so it was straight after all.

In the DSM-IV one was to have strong negative reactions to one’s body, one’s role in society, one’s clothing; sexual preferences also played a role; it was recorded and mostly your becoming gay (post-transition) would be negative specifier.

The current edition now has some improvements. The identity itself is not a disorder anymore, only the dysphoria counts. They say. However this is not all true. To start with: GD gets a category of its own. The positive element in this is it is not placed anymore among the sexual or paraphilic disorders. But why does it need a place in DSM anyway? Because we want treatment costs covered? Then it should be in a medical manual. Since the APA itself also claims the identity is not a disorder, it should have no place. And the mental problems that come from (outside or inside) transphobia don’t need a trans specifier.

To be able to get medical assistance as trans in a country that uses the DSM (and many do) a diagnosis is needed that you experience severe dysphoria, a strong conflict between your anatomy and the idea of who you are. And of course the strong conviction to be of the “the” other gender. That also applies for the Netherlands, not quite so progressive as it sees itself.

Several countries, not the least the USA, use the DSM for their insurance reimbursement and coverage criteria. Where these insurance companies are commercial molochs that have an interest in covering as little as possible, weird things as gender dysphoria only qualify if they exist as a reference/entry in a diagnostic manual. Practically this leads on the one hand to trouble for those who need access and cannot pay for themselves. Ultimately this is a grave and structural human rights violation that takes place in some of the most developed countries. This costs lives.
On the other hand – and not as a compensation but a parallel development – the model that trans* is mostly and heavily relying on medical technology, is less strong there. Other ways to live as trans, other transsexual technologies are found and used. Emphasis may lie stronger on the expression and less on the genitals. Different ways of living their trans life are invented. After all centering on hormone treatment and surgery is something that is only a recent possibility. With diminishing the logic of “trans, thus medical intervention is needed”is othing wrong. With keeping the same rationale for recognition under the new description and still needing medical gatekeepers, all is wrong.

What is needed is an approach that recognises the social-psychological character of gender diversity and takes its departure ppoint in heping the client with what they indicate they need: moslty adaption to growing in their deeply felt identity. Confirmation, not criticising. Help with overcoming the results of transphobia and cisgenderism. This may include medical interventions, but does not need to. When needed, this must be available at a high level of competence and be imbursed by health insurance. Governments should take also trans* related medical assistance within the default care package they regulate imbursement for.

This post highlights some nasty details hiding in the shades of the current Dutch transgender bill, as imposed upon Dutch trans people by obscure deliberations between the Justice ministry and the gender teams. Where informed consent on the one hand is the only criterion for LGR, the gender teams through a back door still have their say who is credible and who is not, who will be recognised and who will be scrutinised.

In many countries medical interventions are required in order to be able to change your gender registration on birth certificate and/or passports. Think France, Spain, US, Scandinavia, Poland, Chile, Brazil Japan, Philippines … From a human rights perspective requiring medical intervention for legal change constitutes a violation of the right to be exempt form medical maltreatment. And recently the UN Special Rapporteur in Torture classified obligatory medical interventions as such. He explicitly mentioned infant genital mutilation and forcible trans genital surgery to equal torture. And then there are countries that do not require it to be so, but do expect it. Even if they say to rely on the informed consent of the applicant. As it stands, the new Dutch law presupposes the wish to medical intervention. Also there are some countries that do not require any medical intervention. Examples are Argentina of course, the UK, Hungary, Portugal …

With the recently adapted legislation for legal gender recognition the Netherlands now opts for a strange hybrid that has some devils hiding in the details. The formal construction to be is that anyone (with a legal registration in the Netherlands) of sixteen years or older can request a confirmation letter of their long term and/or deeply seated feeling of not belonging to the sex/gender they are registered under. The only requirement is they have to understand what they are engaging upon. But as stated: the devil hides in the details. For the professionals allowed to issue such a letter of understanding, are the doctors and psychologists of the gender teams. Which is surprising. If the applicant is not by definition suffering from a mental disorder, then why have them screened by a psychologist? If going down that way, one might expect obstructive co-morbidities. These are given in the explanation of the law: the legislator fears for applications by people suffering from psychoses or other delusions. Not that there have been many reports of misuse. Most psychoses or delusions of people that apply for trans health care interventions, concern trans people with mental coping problems, trans people with co-morbidities. Not madmen playing trans. Nor villains wanting to abuse the system. And anyway, if this might be the case sometimes, the statistics are really low and the harm done is only to themselves. So the legislator is confused, fearful or influenced by the medical establishment.

The second and related problem lies in how the gender teams will react. How they will perform their task. Here word on the street is not really positive either. What is to be expected is a conflation of tasks. On the one hand psychologists still have to inform prospective patients on the medical gender reassignment protocols and procedures. On the other hand they get a new task, to screen if the applicant understands what this change of legal gender entails. When the setting is mostly assisting people with coping with their cross gender feelings, filtering out who is eligible for gender reaffirming treatment, then this is not an illogical step. But the legal requirement is different. The psychologists however – from professional pride? – insist on not just checking the measure of informed consent, but already inform and check the client’s readiness for medical treatment. This does injustice also to the current population of people that come to the gender team. Not all those rejected are not transgender (enough). Also applicants for medical assistance that are not ready for medical treatment – in the current setting or not ready at all – are being turned away.

Up to now everyone passes through a psychological diagnosis of gender dysphoria. If you just want acknowledgement of your identity, partial treatment, the whole package or maybe counselling. No discrimination this way. That starts behind the first gate. It very much looks like the amount of people requesting a consult will grow, potentially a lot, and next there will be quick and a slow path/trajectory. The fast route is for who only wants legal gender recognition. They get in principle one talk and are free to go then. Until they want medical treatment. Group two wants immediately medical assistance. It is not clear now if they will get the offer to first change their gender marker. Or will be side lined with longer waiting times until there is more capacity. Or the other way round: if you only need a certificate, you can wait. This approach is plain wrong. Not from a medical/psychological point of view. Then it is logical to first do a thorough anamnesis. But these people do not come for a medical anamnesis, they want their gender marker changed in order to easier decide how to continue with life. In order to find out how to make sense of their gender difference. Now the processes of gender change have the chance to be more separated, it also could become more clear that there is a need for more counselling. The psychologists at the gender teams only check if you conform enough to the diagnostic criteria for (full) medical treatment. And then they only take your pulse during transition. Which leaves trans people in limbo again for the most important element of health care: support.

So, the applicant for legal gender change who does not want or need (any more) medical assistance inquires at the civil registry for the conditions to change their gender marker and then hears they have to go and see a psychologist or psychiatrist from the gender team. That means the state considers the requester to be mentally incapacitated for an autonomous decision regarding their gender.

Transgender Network Netherlands asked the secretary of Justice for clarification, since he is making a mess of it. I am very curious what he will come up with, but something tells me we still have to wait some years before we will get real informed consent.

Vreerwerk

A Dutch name for thorough LGBTI advocacy and gender education. More than ten years on the theatre of transgender and human rights with an extra-ordinary personal story, I am the 'tranny' for your cause.